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General NPI Number Information
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NPI Number | 1811244007
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Entity Type | Individual
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Provider Name | JENNIFER WEISS PA-C
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Gender | Female
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Dates
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Enumeration Date | 08/07/2012
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Last Update Date | 11/12/2024
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Provider Practice Location Address
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Address Line | 630 W MAPLE ST
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City | FARMINGTON
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State | NM
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Zip | 87401-6113
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Country | US
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Telephone | 505-609-6349
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Fax | 505-599-4679
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Provider Business Mailing Address
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Address Line | PO BOX 844088
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City | DALLAS
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State | TX
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Zip | 75284-4088
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Country | US
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Telephone | 505-609-2258
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Fax | 505-609-2259
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | 0110003901
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License Number State | VA
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Taxonomy #2
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | PA2024-0065
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License Number State | NM
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